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Burnett County 7410 Co. Rd. K, No. 102, Siren, WI 54872 Office of Zoning Administrator d -0 -- 0 <br /> APPLICATION FOR — LAND USE — PERMITS 3. <br /> d <br /> TO THE ZONING ADMINISTRATOR:The undersigned hereby makes application for a Permit for the work described and 6 o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> regulations of th�ee\State of Wisconsin. 1 <br /> TgL)r_ VeLI �� -3ccAzrsoyJ Lo'VS� n hit f <br /> OWNER (Please Print) Co tractor or SuDrveyor or Agent o <br /> 133 hlettJrolr p( Vg9 <br /> Addre s Addr s <br /> -t Cray �u �,�►Sr, v�%ster <br /> City, State, Zip Code City, State, Zip Code D <br /> s4oa� �4 89 3 s <br /> Teleone Telepho e <br /> pV83— 9hocb G <br /> Emergency/Fire No. and Road Name N <br /> Legal Description (as Indicated on tax statement) <br /> = o <br /> Permit(s) Applied for: 5 <br /> Dwelling Addition Filling/Grading Camping Unit <br /> v <br /> Z o <br /> Accessory Building Sanitary Privy Subdivision P $ <br /> Garage �) <br /> Structure Use: i f <br /> (family home/cabin, gar ge, addition, etc.) <br /> DIRECTIONS FOR PLOT PLAN DRAWING: � Dr <br /> 1. Show the location and size of all existing buildings (EB) and all new buildings (NB) and Indicate North (N). O <br /> 2. Show the location of the well (W),septic tank(ST), and drairdield (DF). C 3 N <br /> 3. Show the location of any lake or flowage-if within 1000 ft. and the location of any river or stream-if within P 0- <br /> 300 ft. o i <br /> 4. Show dimensions in feet of the following:(a) building to all lot lines,(b)building to center line of road,(c)building <br /> to lake, river or stream, if applicable. m o <br /> 5. If,separate plans are submitted by an architect,engineer,builder,contractor,etc.,the plans must be signed and C (� <br /> dated by the owner. m � r T -z <br /> PLOT o�PLAN T <br /> A� <br /> 1 10 13 <br /> PAW" Molda� c�taYu^�` 1� sta <br /> � ao� 7Wa <br /> 44dl3 �hciq� 10T 0 <br /> m � Q <br /> g <br /> X90 � <br /> 11K `b <br /> z <br /> � 17 <br /> . Rd <br /> 3 y 4 z j / 7 1 <br /> 2ti,Z PAO, <br /> 30 f \ m oc � mmoagm <br /> c[ IJi iD 9 n� <br /> R3. 0050 <br /> a N a m M <br /> < N o 5,c= — <br /> mwi m <br /> c1 ^ O <br /> ' c E <br /> I declare that this application(including any accompanying schedule)has been examined by me and to the best of my knowl- o ; m m ` : m <br /> edge and belief it is true,correct and complete.I acknowledge that I am responsible for the detail and accuracy of all informs- .� v,ro <br /> tion contained in this application(including any accompanying schedule)and I further declare that I recognize that this infor- <br /> mation I am providing will be relied upon by the County of Burnett Wisconsin in determining whether to issue a permit. 1 8 m g <br /> further accept all liability which may be a result of the County of Burnett relying on this information I am providing in this ap- N <br /> plication. I agree to permit county officials charged with administering county ordinances or other authorized person to have v, <br /> access to the above described premise at any reasonable time for the purpose of inspection. m g <br /> m 3 <br /> � U p N <br /> lD N <br /> H u <br /> SIGN HERE <br /> (signature f o ner bu c ntractor) e�j <br /> ZONING ADMINISTRATOR 8 <br /> g g <br /> OWNSHIP PERMITS MAY BE REOUIRED IIT'( MAY 1 Q I`91 <br /> iI u <br /> C <br />